Urology
Expert guidance on urologic oncology, stone disease, BPH management, incontinence, and minimally invasive surgical approaches.
Recent Discussions
Can retrograde ejaculation be caused by prostate radiation?
It is important to first recall the pathophysiology of normal ejaculation. The initial step in semen emission is closure of the bladder neck, which is mediated by innervation from the sympathetic nervous system. Retrograde ejaculation occurs from an incompletely closed bladder neck, which most frequ...
How do you advise your patients to optimally store a recently passed kidney stone to ensure it can later undergo composition testing?
I am not aware that kidney stone composition changes significantly ex vivo. Calcium oxalate dihydrate will gradually change to monohydrate, but that does not influence my treatment recommendations. The more challenging problem is capturing the stone for analysis. For patients with colic, I send them...
How do you approach treatment of localized small cell bladder cancer?
Localized small cell bladder cancers often are upstaged at surgery and show aggressive behavior. I offer 3 months of neoadjuvant chemotherapy (Cisplatin and Etoposide), followed by radical cystectomy for most patients who are surgical candidates (see MD Anderson data, Lynch et al, Eur Urology, PMID ...
What prostate size, if any, is a relative contraindication for external beam RT?
I do not view the prostate size itself as a contraindication on its own to EBRT. I believe the largest prostate I have treated was ~350 cc. The things to keep in mind when treating any prostate patient, but especially when gland sizes are large, are: 1. How well was the gland sampled? MRI can be ver...
Would you recommend treating asymptomatic bacteriuria in a kidney transplant patient who has a ureteral stent in place?
An exercise in futility. You can eradicate for a short period - long enough to safely perform a urologic procedure. But longer term? Fugetaboutit.
Do you transition to non-tablet formulations of potassium citrate in patients with recurrent calcium oxalate nephrolithiasis and hypocitraturia who are noticing intact tablets in their stool?
Wax matrix slow release tablets release their contents but need not dissolve and are often seen by patients. I never change meds just because of signs of the tablets, I watch the 24 hour urine K, citrate, pH, and the balance between ammonia and sulfate. If the pills are working K and pH and citrate ...
Do you recommend bone mineral density testing in your patients with recurrent nephrolithiasis secondary to medullary sponge kidney?
A majority of patients classified as MSK do not have that disease. They are calcium phosphate stone formers with multiple duct of Bellini crystal plugs. Most of those have idiopathic hypercalciuria and in that genetic syndrome bone mineral loss is not at all uncommon. Some patients - but by no means...
Would you consider omitting adjuvant durvalumab in MIBC to limit overtreatment in patients who may not benefit or those who have achieved maximal benefit after neoadjuvant gem/cis/durva?
The NIAGARA protocol included neoadjuvant durvalumab in combination cisplatin/gemcitabine, followed by adjuvant durvalumab regardless of the pathologic response at the time of surgery. Therefore, even those with pCR completed the year of adjuvant therapy. What is important to point out is that we do...
Given RADICALS-HD, are you completing 24 mo vs 6 mo of ADT with XRT following RP?
Initial: We know 2 years of ADT works. Adding to the classic RTOG 9601, RADICALS-HD demonstrated an improvement in the primary and clinically-relevant endpoint of MFS.Who should be offered 2 years is a more nuanced question. I rely heavily on the PSA to guide as I am influenced by the significant in...
Do you recommend treating asymptomatic Proteus urinary infections in patients with alkaline urine and recurrent calcium phosphate nephrolithiasis?
Yes! Proteus species are typically rapid producers of urease, splitting urea to ammonium and raising urine pH, often into the high 7s and precipitating, magnesium, ammonium phosphate stones, otherwise known as struvite.Your patient’s Proteus infection apparently splits urea more slowly with less ele...